Nurses in medical error get "re-education"

Updated 10:49 pm, Friday, June 20, 2014

The five nurses linked to misuse of insulin pens at Derby's Griffin Hospital will not be terminated or suspended, a hospital spokesman said.

Meanwhile, the hospital has tested almost 1,000 patients for HIV and hepatitis as a result of the error, and hopes to test another 2,000.

In May, hospital officials announced that pieces of a small number of insulin pens, used primarily to treat diabetes, had been used on more than one patient, leading to possible contamination.

The misuse happened between 2008, when the hospital started using the pens, and May 14 of this year, when the hospital stopped using them. Griffin sent letters to the 3,148 patients on whom the pens had been used, urging them to be tested for HIV, Hepatitis B and Hepatitis C.

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Facts on Griffin insulin pen testing:• 3,149 patients received the pens during the six years they were in use. In case any of them are among those on whom part of the pens were reused, they all urged to undergo testing for Hepatitis B, Hepatitis C and HIV.• 979 patients have been tested so far• 1,132 appointments for testing have been booked, including those who have booked appointments for re-testing

When news of the flap broke, Griffin officials said they had identified five nurses who either misused the pens or witnessed the misuse. At that time, hospital President and CEO Patrick Charmel said the nurses would be "disciplined," but indicated that the punishment wouldn't be severe.

On Friday, hospital spokesman Ken Roberts confirmed that major action, including firing, won't be taken against the nurses. He said that decision was made after an investigation by the hospital showed the nurses hadn't misused the equipment intentionally.

"I assure you, if someone did something willfully, wrong, it would be a different action," Roberts said.

He said the hospital has counseled all the involved nurses, but couldn't say what, if any other action had been taken. One of the reasons severe punishment was avoided was that the problem came to light because nurses came forward about it.

"If someone does self-report (a problem) and they get kind of whacked for it, then people won't want to report" these incidents, Roberts said.

He added that the real cause of the problem was a lack of training about the insulin pens, and nurses and other hospital staff are being "re-educated" about the safe use of hospital equipment.

At least one patient advocate thinks Griffin made the right move in not severely punishing the nurses.

"I think there's something to acknowledging that something in the system was really wrong and not placing the blame on individuals," said Jean Rexford, executive director the Connecticut Center for Patient Safety, a Redding-based watchdog group.

She said these kinds of complications can happen when a hospital introduces a new product.

The insulin pens in question, produced by Novo Nordisk, are injector devices with an insulin cartridge. The needle on the insulin pen is removable, allowing reuse of the pen-like injector. Though the pens can deliver multiple doses of medicine, they aren't meant to be used on more than one person.

"Here was a technology that was user friendly, but did people stop and think what could go wrong?" Rexford said.

The hospital continues to test patients for possible infection from the pen misuse. As of Friday, 979 patients had been tested, and 1,132 testing appointments had been booked.

Depending on when they were initially in the hospital, some patients will need to be retested, Roberts said, as some of these illnesses don't always immediately show up in testing. Because of the need for retesting, Roberts said, the hospital is holding off releasing any testing results.

"We won't know for certain about (some of ) these folks for quite some time," he said.